Follow-up Compliance in Patients Undergoing Abdominal Aortic Aneurysm Repair at Veterans Affairs Hospitals

Introduction The Society for Vascular Surgery guidelines recommend annual imaging surveillance following endovascular aneurysm repair (EVAR) and every five years following open surgical repairs (OSR) of abdominal aortic aneurysms (AAA). Adherence to these guidelines is low outside of clinical trials and compliance at Veterans Affairs (VA) hospitals is not yet well established. We examined imaging follow-up compliance and mortality rates after AAA repair at VA hospitals. Methods We queried the VA Surgical Quality Improvement Program (VASQIP) database for elective infrarenal AAA repairs, EVAR and OSR, then merged in follow-up imaging and mortality information. Mortality rate over time was derived using Kaplan-Meier estimation. Generalized Estimating Equation with a logit link and a sandwich standard error estimate was performed to compare the probability of having annual follow-up imaging over time between procedure types and to identify variables associated with follow-up imaging for EVAR patients. Results Our analysis included 11,668 patients who underwent EVAR and 4,507 patients who underwent OSR at VA hospitals between the years 2000-2019. The 30-day mortality rate for EVAR and OSR was 0.37% and 0.82%, respectively. OSR was associated with lower long-term mortality after adjusting age, sex, ASA classification and pre-op renal failure with an adjusted hazard ratio of 0.88 (95% confidence interval: 0.84-0.92, P<0.01). Of surviving patients, the follow-up imaging rate was 69.1% by 1 year post-EVAR. Follow-up rate after 5 years was 45.6% post-EVAR compared to 63.6% post-OSR of surviving patients. A history of smoking or drinking, baseline hypertension, and known cardiac disease were independently associated with poor follow-up after EVAR. Conclusions Patients undergoing elective Open AAA repair in the VA hospital system had lower long-term mortality compared to patients who underwent endovascular repair. Compliance with post-EVAR imaging is low. Patient factors associated with poor post-EVAR imaging surveillance were smoking within the last year, excess alcohol consumption, and cardiac risk factors including hypertension, prior myocardial infarction, and congestive heart failure.